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Kumar NL, Travis AC, Saltzman JR. Initial management and timing of endoscopy in nonvariceal upper GI bleeding. Gastrointest Endosc 2016; 84:10-7. [PMID: 26944336 DOI: 10.1016/j.gie.2016.02.031] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 02/18/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Navin L Kumar
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Anne C Travis
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Acute nonvariceal upper gastrointestinal bleeding remains an important cause of hospital admission with an associated mortality of 2-14%. Initial patient evaluation includes rapid hemodynamic assessment, large-bore intravenous catheter insertion and volume resuscitation. A hemoglobin transfusion threshold of 7 g/dL is recommended, and packed red blood cell transfusion may be necessary to restore intravascular volume and improve tissue perfusion. Patients should be risk stratified into low- and high-risk categories, using validated prognostic scoring systems such as the Glasgow-Blatchford, AIMS65 or Rockall scores. Effective early management of acute, nonvariceal upper gastrointestinal hemorrhage is critical for improving patient outcomes.
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Affiliation(s)
- Tracey G Simon
- Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02215, USA
| | - Anne C Travis
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Abougergi MS, Travis AC, Saltzman JR. The in-hospital mortality rate for upper GI hemorrhage has decreased over 2 decades in the United States: a nationwide analysis. Gastrointest Endosc 2015; 81:882-8.e1. [PMID: 25484324 DOI: 10.1016/j.gie.2014.09.027] [Citation(s) in RCA: 154] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 09/10/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite major advances in upper GI hemorrhage (UGIH) treatment, UGIH mortality has been reported as unchanged for the past 50 years. OBJECTIVE To measure the UGIH in-hospital mortality rate and other important outcome trends from 1989 to 2009. DESIGN A longitudinal study of UGIH hospitalizations by using the Nationwide Inpatient Sample. SETTING Acute-care hospitals. PATIENTS All patients admitted for UGIH. Patients who bled after admission were excluded. MAIN OUTCOME MEASUREMENTS UGIH in-hospital mortality rate, incidence, in-hospital endoscopy and endoscopic therapy rates, length of hospital stay, and total in-hospital charges. RESULTS The non-variceal UGIH mortality rate decreased from 4.5% in 1989 to 2.1% in 2009. The non-variceal UGIH incidence declined from 108 to 78 cases/100,000 persons in 1994 and 2009, respectively. In-hospital upper endoscopy and endoscopic therapy rates increased from 70% and 10% in 1989 to 85% and 27% in 2009, respectively. The early endoscopy rate increased from 36% in 1989 to 54% in 2009. The median length of hospital stay decreased from 4.5 days in 1989 to 2.8 days in 2009. Median total hospitalization charges increased from $9249 in 1989 to $20,370 in 2009. At the national level, the UGIH direct in-hospital economic burden increased from $3.3 billion in 1989 to $7.6 billion in 2009. Similar trends were found for variceal UGIH. LIMITATIONS Retrospective data, administrative database. CONCLUSION In-hospital mortality from UGIH has been decreasing over the past 2 decades, with a concomitant increase in rate of endoscopy and endoscopic therapy. However, despite decreasing length of stay, the total economic burden of UGIH is increasing.
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Affiliation(s)
- Marwan S Abougergi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne C Travis
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Abougergi MS, Travis AC, Saltzman JR. Impact of day of admission on mortality and other outcomes in upper GI hemorrhage: a nationwide analysis. Gastrointest Endosc 2014; 80:228-35. [PMID: 24674354 DOI: 10.1016/j.gie.2014.01.043] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Accepted: 01/23/2014] [Indexed: 01/23/2023]
Abstract
BACKGROUND Studies have reached varying conclusions regarding the association between day of admission and outcomes in patients with upper GI hemorrhage (UGIH). OBJECTIVES To evaluate whether important outcomes in UGIH, including in-hospital mortality, differ between patients admitted on weekends versus weekdays. DESIGN AND SETTING Retrospective cohort study by using the 2009 Nationwide Inpatient Sample. PATIENTS Patients were included if they were adults with a principal diagnosis of acute UGIH. Patients admitted between midnight Friday and midnight Sunday were classified as weekend admissions. MAIN OUTCOME MEASUREMENTS In-hospital mortality, in-hospital endoscopy, endoscopic therapy, length of stay, and total hospitalization charges. RESULTS The study included 199,008 patients with nonvariceal UGIH and 3251 patients with variceal UGIH. Compared with patients admitted on weekdays, patients with nonvariceal UGIH admitted on weekends had similar adjusted in-hospital mortality rates (odds ratio [OR] 1.11; 95% confidence interval [CI], 0.93-1.30), endoscopic therapy rates (OR 0.98; 95% CI, 0.92-1.04), and length of stay (P = .09), but had lower early endoscopy rates (within 24 hours)(OR 0.64; 95% CI, 0.60-0.67), lower in-hospital endoscopy rates (OR 0.84; 95% CI, 0.78-0.91), and higher hospitalization charges (mean increase, $1558; P = .01). Patients with variceal UGIH admitted on weekends and weekdays did not differ in any of these outcomes. LIMITATIONS Retrospective data, administrative database. CONCLUSIONS Compared with patients admitted on weekdays, patients with nonvariceal UGIH admitted on weekends had similar mortality rates and lengths of stay, but lower endoscopy rates and higher hospitalization charges. Patients with variceal GI hemorrhage had similar outcomes regardless of day of admission.
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Affiliation(s)
- Marwan S Abougergi
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne C Travis
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Hyett BH, Abougergi MS, Charpentier JP, Kumar NL, Brozovic S, Claggett BL, Travis AC, Saltzman JR. The AIMS65 score compared with the Glasgow-Blatchford score in predicting outcomes in upper GI bleeding. Gastrointest Endosc 2013; 77:551-7. [PMID: 23357496 DOI: 10.1016/j.gie.2012.11.022] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 11/19/2012] [Indexed: 02/06/2023]
Abstract
INTRODUCTION We previously derived and validated the AIMS65 score, a mortality prognostic scale for upper GI bleeding (UGIB). OBJECTIVE To validate the AIMS65 score in a different patient population and compare it with the Glasgow-Blatchford risk score (GBRS). DESIGN Retrospective cohort study. PATIENTS Adults with a primary diagnosis of UGIB. PRIMARY OUTCOME inpatient mortality. SECONDARY OUTCOMES composite clinical endpoint of inpatient mortality, rebleeding, and endoscopic, radiologic or surgical intervention; blood transfusion; intensive care unit admission; rebleeding; length of stay; timing of endoscopy. The area under the receiver-operating characteristic curve (AUROC) was calculated for each score. RESULTS Of the 278 study patients, 6.5% died and 35% experienced the composite clinical endpoint. The AIMS65 score was superior in predicting inpatient mortality (AUROC, 0.93 vs 0.68; P < .001), whereas the GBRS was superior in predicting blood transfusions (AUROC, 0.85 vs 0.65; P < .01) The 2 scores were similar in predicting the composite clinical endpoint (AUROC, 0.62 vs 0.68; P = .13) as well as the secondary outcomes. A GBRS of 10 and 12 or more maximized the sum of the sensitivity and specificity for inpatient mortality and rebleeding, respectively. The cutoff was 2 or more for the AIMS65 score for both outcomes. LIMITATIONS Retrospective, single-center study. CONCLUSION The AIMS65 score is superior to the GBRS in predicting inpatient mortality from UGIB, whereas the GBRS is superior for predicting blood transfusion. Both scores are similar in predicting the composite clinical endpoint and other outcomes in clinical care and resource use.
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Affiliation(s)
- Brian H Hyett
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
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Agrawal JR, Travis AC, Mortele KJ, Silverman SG, Maurer R, Reddy SI, Saltzman JR. Diagnostic yield of dual-phase computed tomography enterography in patients with obscure gastrointestinal bleeding and a non-diagnostic capsule endoscopy. J Gastroenterol Hepatol 2012; 27:751-9. [PMID: 22098076 DOI: 10.1111/j.1440-1746.2011.06959.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM In patients with obscure gastrointestinal (GI) bleeding, capsule endoscopy is widely used to determine the source of bleeding. However, there is currently no consensus on how to further evaluate patients with obscure GI bleeding with a non-diagnostic capsule endoscopy examination. This study aims to determine the diagnostic yield of dual-phase computed tomographic enterography (CTE) in patients with obscure GI bleeding and a non-diagnostic capsule endoscopy. METHODS Patients with obscure GI bleeding who were referred for capsule endoscopy were prospectively enrolled. Obscure GI bleeding was defined as overt if there was obvious GI bleeding; otherwise it was defined as occult. Patients with a non-diagnostic capsule endoscopy and no contraindications underwent a CTE. RESULTS Capsule endoscopy was performed in 52 patients; 26 patients (50%) had occult GI bleeding and 26 patients (50%) had overt GI bleeding. CTE was then performed in 25 of the 48 patients without a definitive source of bleeding seen on capsule endoscopy. The diagnostic yield of CTE was 0% (0/11) in patients with occult bleeding versus 50% (7/14) in patients with overt bleeding (P < 0.01). Using clinical follow up as the gold standard, for the 25 patients with a non-diagnostic capsule, CTE had a sensitivity of 33% (95% confidence interval 0.15, 0.56) and a specificity of 75% (95% confidence interval 0.22, 0.99). CONCLUSIONS In patients with a non-diagnostic capsule endoscopy examination, CTE is useful for detecting a source of GI bleeding in patients with overt, but not occult, obscure GI bleeding.
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Affiliation(s)
- Jaya R Agrawal
- Gastroenterology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Affiliation(s)
- Anne C Travis
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Abstract
BACKGROUND AND AIM Following endoscopic therapy, up to 20% of patients with non-variceal upper gastrointestinal hemorrhage experience rebleeding. The aim of the present study was to determine risk factors for recurrent hemorrhage in these patients. METHODS This was a retrospective cohort study of consecutive patients admitted to a tertiary care hospital between 1 July 1999 and 30 June 2004, with non-variceal upper gastrointestinal hemorrhage. Patients were evaluated for rebleeding within 30 days of successful therapeutic endoscopy. Using the hospital's endoscopic database, 236 patients were identified. Risk factors were identified using multivariable logistic regression with backward selection. Internal validation was carried out using bootstrapping. RESULTS Six risk factors were identified: failure to use a proton pump inhibitor post-procedure (P = 0.056), Endoscopically demonstrated bleeding (P = 0.053), peptic ulcer as the bleeding source (P = 0.018), treatment with epinephrine monotherapy (P = 0.0026), post-procedure intravenous or low molecular weight heparin use (P = 0.0014), and moderate or severe cirrhosis (P = 0.032) (PEPTIC). The risk of rebleeding increased as the number of risk factors present increased. The observed rates of rebleeding were: 7.1%, 16.4%, 37.0%, 75.0% and 100% for zero, one, two, three or four risk factors, respectively (no patients had five or six risk factors present). The bias-adjusted area under the receiver-operator characteristic curve for the number of risk factors predicting rebleeding was 0.69. CONCLUSIONS We have identified six easily remembered risk factors, which, when summed, predict recurrent hemorrhage following endoscopic therapy for non-variceal upper gastrointestinal hemorrhage.
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Affiliation(s)
- Anne C Travis
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Affiliation(s)
- A R Thorner
- Dana-Farber Cancer Institute, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
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